Cholesterol Craze

Don’t you just love the world of medicine? We can take just about any condition and make it seem so incredibly complicated that no mere mortal could ever comprehend. Just listen to what we say, swallow the pill and you’ll get better. No need for you to worry your pretty little head with all the details that are far too complicated for your simple, uneducated mind to understand.

I don’t know about you, but that kinda irritates me a bit. A lot, actually. Medicine has done a pretty good job keeping up its high level of mystique from as far back as ancient Babylon…right up until Dr. Google came on the scene. With all the info so readily available nowadays, its not uncommon for patient’s to know more about their medical conditions than their doctors. Unfortunately, there remains a gap in the information out there on the beloved inter-webs. If you look hard enough, you will find a wealth of contradictory information, especially on hot topics like the one we’re gonna talk about today, cholesterol.

I know, I know…not again. You’ve already heard all this. Stop eating eggs and red meat, get a little exercise, take the statin med my doc gave me and I’m good. Oh, maybe take some fish oil or did that cause prostate cancer? Wait, are eggs really bad or is it ok to have eggs again? Before we jump off into the things to do and not do for better cholesterol, let’s first understand why we look at cholesterol and some of the shenanigans surrounding the testing itself.

Since this is a men’s health forum, its cool to know that the hormone Testosterone is constructed in the body by starting with cholesterol. In fact, most all of the sex hormones start out as cholesterol from LDL (low density lipoprotein) or the “bad” cholesterol. So, if glorious things like Testosterone are made from LDL cholesterol, why does it get the bad wrap?

To understand the answer to this question, its helpful to understand what we’re actually talking about in medicine when we’re looking at cholesterol labs. Of course, to understand the labs, you’ll need a brief anatomy lesson on cholesterol. Bare with me, I’ll make it as painless as possible.

First off, cholesterol is a fat. Humans are a water-based organism. Fat and water don’t mix, right? If you’ve never done it, pour some vegetable oil (fat) into some water and watch the oil float on top of the water. Even if you shake it up, the oil will not dissolve into the water (unless you add mustard…cool experiment to do with the kids). Same goes with cholesterol (fat) in our watery body, the blood specifically. To get the cholesterol dissolved in our blood and move it around, it must be packaged inside a water soluble membrane. We call these packages, particles or lipoproteins (lipo meaning fat and protein meaning…well you know). There are different types of particles (lipoproteins) based on how densely our body packs in the cholesterol and other stuff (triglycerides) into the particle. How densely the cholesterol is packed in determines the type of particle. Ex - low density (LDL) vs high density (HDL). Below you’ll see a pretty picture that shows what we’re talking about.

LDL Particle showing cholesterol and triglycerides packed inside.

The key take-away here is that there is a difference between cholesterol (stuff inside the particle) and the particle or package itself. The particles are not all created equally. For example, LDL particles which are “low density” overall, can be larger, more “fluffy” or buoyant and very low density (VLDL) or intermediate density (IDL). LDL particles can also be smaller and of different densities called sLDL particles. What medical science has discovered more recently is that it is the size and type of particles that creates risk for things like heart disease and stroke, NOT the cholesterol inside the particles. Read that again. That’s correct, the cholesterol (stuff inside the particle) is not the issue. Specifically, it is the number of small LDL particles (sLDL-p) that has the greatest impact on risk of developing heart disease or stroke. The larger, “fluffier” LDL particles play some role but only when present in high quantities. Problem is, the tests most doctors use to evaluate cholesterol, called a standard lipid panel, tells us nothing about the number and types of particles, only the cholesterol inside them. So why do we measure cholesterol and make all the fuss about it? Good question.

To better illustrate the point, or perhaps pointlessness, of standard lipid testing, let’s take a look at some real labs.

Not too shabby, right? Everything here appears to be in order.

Here’s the deets on the dude: This panel comes from a 50 y.o. male with no significant medical issues other than high blood pressure that is well controlled on a single medication for several years per his prior standard lipid panel results. He has no significant family history. He’s 5’10” and weighs 210lbs. Average build with more overall body fat than muscle. What some might call, “pudgy”. He was interested in weight loss, so we started with some labs that included a fasting insulin level. We discovered that his insulin was about 3 times higher than desired. Since insulin plays a huge roll in how we create and package cholesterol, we decided to do a little deeper dive into his lipids just to be sure. Here’s what we found:

Wait, what’s all that stuff in red? I thought the standard lipid panel was spot on normal? What the heck happened?

This additional panel is what we call an NMR lipid particle count. The results are a little more detailed, but to save you a total geek out session, I just used this part to make my point, and yes, it IS from the same person and even the same blood sample on the same day and time!

This NMR panel gives us the actual count of the LDL (big and fluffy), small LDL (sLDL) and HDL particles. Not just how much cholesterol is in them which is what we see on the standard lipid panel. Remember, its the small LDL (sLDL) particles that increase the risk for heart disease NOT the cholesterol inside them. Reason being, the small LDL particles have a longer life span and are more prone to oxidation and becoming “stuck” to the walls of the blood vessels forming plaques.

You can clearly see that even with a normal LDL-cholesterol number, the actual particle counts can be not so great. Fortunately for this fellow, the values here, while higher than we would want, would put him in an “intermediate risk” category even though he’s on medication. After a lengthy discussion about dietary do’s and don’ts, he was able to get this down in the optimal range and not require any increases in his medication treatment.

One more note before we wrap this up for now. You probably noticed on the standard lipid panel, the LDL cholesterol has the term CALC. This means the value is actually calculated using a formula (with some constants in it that assumes every human packages fats the same) and really just estimates how much cholesterol may be found in the LDL particles. Just one more reason not to base treatment decisions solely on these types of results.

Whew…glad that’s over? Here’s the message I want you guys to hear: When you get cholesterol results from a standard lipid panel that says either your all good or not, remember those panels are a “screening”. There are other factors, more important ones, that should drive decisions like taking statin drugs, other treatments or even not treating cholesterol at all. If you have a personal or family history of heart disease, stroke or high cholesterol or have concerns, find a doc that understands what to look for, how to do proper lipid testing and interpret the results.

Ask the hard questions and demand real answers. Don’t just take the drug and shut up.

Alpha Male. No apologies.